General Principles in Older Adults
Older patients are more likely than younger patients to have a cardiac event in the absence of chest pain or present to medical care with an atypical clinical presentation of chest pain. Fewer than half of patients whose ultimate diagnosis is acute myocardial infarction (MI) are admitted for acute MI. The National Registry of Myocardial Infarction (NRMI) showed that only 40% of older patients’ chief complaints were chest pain, compared to 77% of patients presenting with MI age 65 years or younger. Patients may present with nausea, fatigue, or delirium. The lack of typical symptoms can lead to treatment delay and increased morbidity and mortality in the older patient population (see Chapter 7, “Atypical Presentations of Illness in Older Adults”). For adults age 65 years or older, ischemic heart disease accounts for 81% of mortality, and should therefore be the first diagnosis considered when an older adult presents for medical care with chest pain. However, chest pain in older patients can also be noncardiac in origin or of a cardiac etiology other than coronary artery disease. Noncardiac origins of chest pain include pulmonary and esophageal. Although not all causes of chest pain in the older adult will lead to fatal events, timely diagnosis based on a history of associated factors and a targeted physical exam can improve an older patient’s health outcomes in the short-term, as well as longer-term quality of life, functionality, and health outcomes. It is therefore essential that clinicians take a thorough history, perform a targeted physical exam, and have a high level of suspicion to make the correct diagnosis in a timely manner.
Typical angina at any age presents as substernal chest pain, often described as “pressure like,” with radiation to the jaw, neck, or arm. If a patient has experienced an MI in the past, asking the patient if this pain is similar to that experienced during a previous MI can be an important clue. Descriptions of chest pain radiating to the back, may be more suggestive of aortic dissection or gastrointestinal pathology such as esophageal reflux. If patients complain that they feel chest pain after eating or when lying flat, one should consider gastroesophageal reflux as a possible diagnosis.
Features suggesting acute coronary syndrome include diaphoresis, cool clammy skin, new or progressive shortness of breath, and/or exertional shortness of breath. Older patients are typically more likely to delay seeking medical care, or be more inclined to attribute their symptoms to “normal aging,” which can lead to increased adverse outcomes or death if the etiology of the chest pain is serious in nature. Most older adults with acute coronary syndrome present to medical professionals with dyspnea, diaphoresis, nausea/vomiting, and/or syncope, and not necessarily with chest pain. In addition, given that older adults have a higher prevalence of comorbidities, concurrent disease processes may cloud ...